We want to use this day to remind moms and dads that hepatitis is around and some of it can be prevented by vaccination.

Hepatitis C is a bloodborne virus that attacks the liver. It is not vaccine-preventable. If babies are infected it’s usually from their hepatitis C+ mothers or, and this is unlikely these days, from a blood transfusion. It’s unlikely because the screening process of donated blood is pretty darn thorough. But, germs have slipped through that screening process.

Teens and young adults may become infected, primarily through sharing of needles, sex with an HCV+ person, or sharing personal items such as razors or toothbrushes that may be contaminated with HCV.

There are effective treatments that work on a good portion of hepatitis C-infected children. But not on all infected children. Work is ongoing in this area.

Hepatitis C is frequently a chronic infection, meaning that if treatment is not effective, you will be infected for your lifetime.

Hepatitis A is vaccine-preventable. Normally, it’s passed person-to-person through the fecal-oral route, which is when something you eat or drink has been contaminated with hepatitis A+ poop. If you haven’t been vaccinated, chances are you will become infected.

This virus makes you feel lousy and can, rarely, do serious damage to the body. It does not become a chronic infection. It infects you and then goes away, like a cold virus.

Hepatitis B is vaccine-preventable. It’s transmitted in a lot of ways—mom to newborn, sharing needles or personal items, sex with an infected person, even household (nonsexual) contact. If a mom is aware of her infection prior to giving birth, shots can be given to the baby within 12 hours of birth that are effective at stopping tranmission of the virus from mom to baby. However, when babies are infected, almost half of them in the US will become chronically infected. In developing countries, that figure shoots up to 90 percent.

Today, despite the vaccine, approximately 1,000 babies become chronically infected with hepatitis B each year in the US. Many of the moms-to-be who are infected are unaware of their infection. Every pregnant woman should be tested for hepatitis B so that action can be taken at birth to prevent infection of the newborn.

Hepatitis D is an odd virus. You have to be infected with hepatitis B before you can get hepatitis D. It’s vaccine-preventable in that, if you get immunized against hepatitis B, you won’t be able to get hepatitis D.

Hepatitis E is similar to hepatitis A in the way it is transmitted—the fecal-oral route. It’s rarely a chronic infection. For most people, they get it, get sick, and get over it. It can however be dangerous for pregnant women, with a 10% – 30% fatality rate for this group. It’s not often found in the US but can be easily picked up in some other parts of the world.

That’s about it for hepatitis in the US. To prevent a hepatitis infection (and lots of other infections), wash your hands throughout the day, put barriers between yourself and another person’s blood or body fluid, and use the available vaccines. The trick is to do these things with everyone. It’s impossible to tell who is infected with what, most of the time, so the safest course of action is to assume everyone is infected with something and then act accordingly.

Some parents wonder about their infected children playing sports and possibly infecting others in the process. Parents also wonder how concerned they should be about their children becoming infected from other players living with undiagnosed or undisclosed infections.

Playing sports can be risky in many ways and part of that risk is the potential to become infected with all sorts of germs.

Parents of children living with diagnosed infectious diseases worry that they may be responsible for infecting another child. They wonder if they should inform the coach or the school. They worry that the adults in charge don’t really follow standard precautions, thereby increasing the risk of infections. They want their kids to enjoy life and they want to do the right thing.

The American Academy of Pediatrics issued a policy statement on this dilemma in December, 1999: HIV and Other Blood-Borne Viral Pathogens in the Athletic Setting. In it, the Academy made clear, “Because of the low probability of transmission of their infection to other athletes, athletes infected with HIV, hepatitis B or hepatitis C should be allowed to participate in all sports.”

Participation, however, assumes all athletes and coaches will follow standard precautions to prevent and minimize exposure to bloodborne viruses.

There is no reason to exclude any student from sports if they’re infected with HIV, HBV or HCV. Nor is there a reason to disclose the infection. There are many people living with undiagnosed infections, so it is more prudent to ensure everyone is practicing standard precautions rather than simply excluding those with known infections and not properly protecting all athletes from undiagnosed infections.

Dr. Steven J. Anderson, a pediatrics professor at the University of Washington and a team doctor for many high school athletic teams, ballet companies and the U.S. Olympic Diving Team, suggests children should have access to any sport, except boxing, which the Academy opposes for all youths because of its physical risks.

Pediatricians can avoid reporting a student’s infection, the Academy noted, by making it clear on any participation forms that they support the Academy’s position that all students can participate in all sports and that pediatricians must respect an athlete’s right to confidentiality.

But strict compliance with standard precautions is critical for this open embrace of all athletes, regardless of their infectious status. Dr. Anderson notes that, as a parent, he would make sure that there is a plan in place to handle blood spills, including latex gloves, occlusive dressings, appropriate sterilizing solutions, disposal bags and even a printed protocol for coaches, athletes and officials.

Dr. Anderson does feel that students with infectious hepatitis A (spread through close physical contact with contaminated food, water or skin) or with liver or spleen enlargement should be restricted from contact or collision sports until the liver or spleen has returned to normal size, and the person is no longer contagious.

An article that ran in 2004 in the British Journal of Sports Medicine talked about possible methods of transmission in sports and reported incidents of transmission:

Bleeding or oozing injuries could, in theory, transmit the virus through the mucous membrane or injured skin of other athletes. This risk is considered extremely low. However, contact and collision sports like wrestling or boxing increase that risk. The risk goes down a bit for those playing basketball or soccer, and those playing sports with little physical contact, such as tennis or baseball, are at the lowest risk.

It has been suggested that bloodborne infections may be transmitted through sharing a water container, because bleeding around the mouth is common in contact sport. Therefore it is recommended that water containers should be available individually for each player in contact sports. Athletes should use squeeze water bottles which they do not put in their mouth.

Bloodborne infections can be transmitted through blood doping. There is also a risk from sharing needles which may be associated with drug abuse in sport. Injectable drugs used in sports include steroids, hormones, and vitamins.

Three separate cases of HIV infection associated with sharing needles among bodybuilders have been reported, two in the United States and one in France. It has also been reported that three soccer players from one amateur club were infected with HCV as a result of sharing a syringe to inject intravenous vitamin complexes. Syringes have often been shared by athletes who inject vitamins minutes before a game.

A 1993 study estimated that, in the United States, there were one million people who were either current or past users of anabolic androgenic steroids. Of these, 50% were intramuscular drug users, and about 25% had shared needles. Therefore it seems that the risk of transmission in this way may be considerable among athletes, especially bodybuilders.

So, if your family is getting involved in sports, it would be worth your time to:

When girls first start menstruating, one of the less-talked about side effects is the messiness. A practical mom of an HCV+ teenage girl contacted us to find out just how to deal with potential blood and body fluid exposures in the home and in public areas.

We thought the answers to her questions might serve many families, so we’re posting them here, with thanks to several infection preventionists who pitched in to provide answers!

In no particular order, here are the questions and answers.

Q: What cleaning products can we use to kill the hepatitis C virus?

Hepatitis C is not an easy bug to kill. Store-bought products (such as Lysol®, Clorox® Clean-up® Cleaner with Bleach, or Mr. Clean®) are not effective.

Bleach is questionable with regard to killing HCV. The proper dilution and the state of the HCV will vary the efficacy. If HCV is in a dried state, it is harder to kill than if it’s in a liquid state. With all blood or infected body fluids, the area needs to be physically cleaned first and then disinfected with 1:10 dilution of bleach (one part bleach, 10 parts water), although studies (see references below) are varied on efficacy.

Ethanol in studies does not show efficacy. Hand Hygiene Alcohol MSDS sheets do not list HCV as a bug that is killed by an alcohol hand rinse.

Super Sani-Cloth Wipes to be used on environment, a quaternary in a cloth/wipe form, kills HCV. Although I would like to emphasize that cleaning the environment must occur before any of these products are effective. Clorox® Germicidal Wipes, bleach wipes for the environment, kills HCV.

For any product, the label must be read. If the label states that it kills HCV, then follow the manufacturer’s guidelines with regard to kill time.

For skin that is contaminated with blood, the hands or skin can be cleaned with soap and water. Wet the skin, suds and use friction on the area with soap for 20 seconds or more, and thoroughly rinse the skin with warm water. This is not to kill the virus but an action to rinse the virus off the skin.

Answering these questions was a very useful refresher on bloodborne pathogens. Breaking the chain of infection is key in preventing transmission to others. Each link must be present and in sequential order for an infection to occur. The links are: infectious agent, reservoir, portal of exit from the reservoir, mode of transmission, and portal of entry into a susceptible host.

Q: How does one handle and dispose of soiled sanitary pads, underwear, or tampon applicators? What about the mess that soiled hands leave behind?

There are a variety of products on the market for the disposal of tampons and sanitary napkins (search the internet “products for tampon/sanitary napkin disposal”). The products may have some advantages over a plastic baggie that can be difficult to seal with potentially soiled hands in a restroom stall.

There are towelettes that can kill HCV, but they are not meant for cleaning of skin, just cleaning of surfaces (it takes 3-4 minutes for HCV to be killed on a surface with these products).

Towelettes for hand sanitizing can be used to clean hands prior to leaving the stall— they are available in small packets that can be kept in a purse. Hand washing with soap and water is important before leaving the bathroom, even if towelettes are used to wipe the visible blood off of your fingers, because the towelettes won’t kill HCV, they will just wipe off some of the blood.

When an HCV+ woman is having her menstrual period, she needs to be prepared to dispose of her sanitary napkin/tampon in a way that decreases exposure of her blood to the environment.

When entering a public restroom, she needs to practice procedure that flows from dirty to clean. This means that prior to entering the restroom stall, she needs to have the items to complete this process—napkin/tampon, disposal bag, disinfectant wipes, and hand cleaning wipes.

She should then get the items out of her purse if there is a place/shelf to put them. If there is not a place, then she should at least put them at the top of her purse, so she is not digging around for them when she needs to use them. Next step is to open the items she needs, such as disposal bag.

Remember, if she is in a public restroom with the designated metal disposal box with leak proof bag she does not have to put her napkin/tampon in a separate bag unless it is very soiled and leaky (that is to reduce contamination of the metal box as it is placed in it). The rationale for this is that the special metal containers are meant for everyone’s napkin/tampon, and all items should be treated as potentially infectious, not just one individual’s napkin/tampon.

The restroom cleaning person’s job description to empty and clean that container falls under the OSHA mandate to receive education and training for bloodborne pathogens. They should know how to properly handle this by using proper personal protective equipment.

While she is removing her napkin/tampon, it might be best to use her less dominant hand so she will have her dominant hand with better control to reach for the disposal bag on top of her purse.

If she has any soiled underwear, she should replace it at this time using a separate disposal bag since she will bring it home to wash. After removing and replacing the napkin/tampon, she needs to clean the environment of any visible blood with the disinfectant wipes. Put the used disinfectant wipes in either the special metal box, if available, or the disposal bag that contains her used napkin/tampon.

If she has visible blood on her hands, she should use the hand cleaning wipes. Also, put the used hand wipes in either the special metal box, if available, or the disposal bag that contains her used napkin/tampon.

Once she leaves the stall, she needs to do hand hygiene at the sink with soap and water. Research has shown that we need to pay attention to cleaning our thumbs, between fingers, around our wrist, and our dominant hand. Also, once she is finished with water, soap, and drying her hands, she should use a paper towel to turn off the faucet and to open the bathroom door, since so many people open the door without doing hand hygiene.

As for her soiled clothes, if she is away from home she should remove them and place them in a plastic bag with the intent of removing the items as soon as she gets home. If it will be awhile before she will return home, she might want to add some water to the bag to keep it moist.

Once she is home, she should place the soiled item in a designated bucket to soak. If someone else is handling her soiled clothes, they should wear gloves. Also, remember to not hold the soiled items next to your clothes. If there is excessive blood or blood clots, they should be mechanical removed either with gloved hands or brush. Next step is to spray some stain remover on the area. OxiClean® is one product that works on red stains. Remember to follow the manufacturer’s instructions. For OxiClean®, spray it on the stain until it’s saturated, rub in, and let stand for up to 10 minutes. Do not let OxiClean® dry on fabric.

(Another infection preventionist contributed quite a bit to this answer, but due to her workplace, she asked that we not share her name.)

Q: What precautions should be taken around the house?

Standard precautions (acting under the assumption that all blood and body fluids are potentially infectious) can and should be followed at home, especially for people living with HCV, in order to prevent the transmission of the virus to others.

Casual contact, such as sharing household items (dishes, cups, and glasses) is not a risk. But blood, body fluids, and items that come in contact with blood are possibly infectious.

Cleaning up blood spills and not sharing household grooming equipment (such as razors, nail clippers, and toothbrushes) will keep people and their families safe from HCV and other infections.

LAUNDRY:

Clothes may be washed together with regular detergents

Use gloves when handling any clothes stained with blood, semen, or vaginal fluids

Wash blood-stained items in hot soapy water using one cup of bleach per load

If items cannot go into the wash, wipe them dry and take them to the dry cleaners

Wash contaminated items with hot water and detergent for at least 25 minutes. Presoaking may be required for heavily soiled clothing. The most important factor in laundering clothing contaminated is elimination of potentially infectious agents by soap and hot water.

Per VA Department of Health

PRECAUTIONS FOR BLOOD SPILL CLEAN-UP

When cleaning up blood spills, the following steps are important for preventing the spread of bloodborne infections like HCV:

Wear gloves—torn gloves will not protect the hands from coming into contact with the blood.

Carefully remove any sharp pieces, such as broken glass, and put them in a sturdy plastic container like one used for detergents.

Wipe up the blood using paper towels or disposable rags and cloths.

Disinfect the area with a solution of at 1 part bleach to 9 parts water. [note the difference in solution compared to Cathy’s in the first Q/A – perhaps take your pick?]

Wipe up the bleach solution using paper towels or disposable rags and cloths.

Dispose of the gloves, paper towel, rags and cloths into a durable bag.

There exist significant challenges to diagnosing and linking to treatment large numbers of hepatitis B virus (HBV)- and hepatitis C virus (HCV)-infected patients who are unaware of their serostatus and thus are not on either anti-HBV or anti-HCV treatment. Additionally, bottlenecks preventing expanded access to HBV and HCV care must be addressed in light of shifting treatment paradigms, which requires an expanded number of clinicians from multiple disciplines to deliver HBV and HCV care.

Presentations will feature state-of-the-art information on HBV and HCV research, clinical perspectives, and medical treatment, both within the context of HBV and HCV monoinfection, as well as coinfection with HIV. The conference will feature 24 oral abstract presentations, poster sessions, plenary presentations, invited panel discussions, and clinical case study reviews.

A couple of findings from the conference that could interest parents of HCV+ kids include:

Forty percent of HCV+ patients are not adhering to their treatment. The key to this is identifying those patients who are depressed and treating the depression along with the disease. Those who were treated for their depression showed higher rates of adherence and, consequently, higher rates of viral suppression.

SPRINT-2 was a study of previously untreated HCV+ genotype 1 patients looking at boceprevir with peginterferon/ribavirin. In this study, this combination of drugs increased sustained virologic response significantly over standard therapy. Another study looked at patients who had been previously treated with standard therapy but either did not respond to treatment or relapsed. For those patients, boceprevir was added in re-treatment and significantly higher rates of sustained virologic response were achieved.

These studies were not performed on children, but we know that what works in the adult population will eventually find its way to the pediatric population.

Blogging is therapeutic. For those living with or affected by infectious diseases, it can be a way to connect with those whose lives mirror their own.

Brooke Davidoff, diagnosed HIV positive in January 2010, blogs about her life as a newlywed and a first-time mom. Brooke’s life turned upside down during her pregnancy, when she had a routine blood test for HIV and discovered she was positive. “If there was no baby, I’d still have no idea,” she blogged.

Brooke started blogging “. . . to express myself, I don’t know how not to. When I was diagnosed, I searched for stuff written by other HIV positive females to relate to, and I had a very hard time finding what I was looking for. So I began to write it for other women like me who needed to know they are not alone.”

Sabina is a 15-year-old girl who loves volleyball and dancing. She’s slogging through a year of treatment for hepatitis C and blogs about it “. . . to share my experience of HCV treatment for children or adults who are starting or already started their treatment. I know that treatment can be difficult and painful, I would just like to give another perspective. I just want to help out and be there for other kids or adults.”

Elizabeth Boskey, PhD, MPH, calls on her education and research experience each time she blogs about STDs. Ever the teacher, Elizabeth says, “There is a lot of secrecy and stigma surrounding STDs. I blog about STDs not only to address the misconceptions about them, but to make them a topic of discussion.

“Some people think that having an STD means that they’re dirty or ruined, that infection marks them as a slut or somehow undesirable—all of which is ridiculous. Still, these feelings are common in people who have had bad experiences disclosing an STD to a partner, or who have simply internalized the stigma that is widely present in American society.

“People make jokes, and not kind ones, about STD infection, but the truth is that STDs are just diseases like any other. Yes, they are often preventable, and people should do their best to prevent them, but acquiring an STD doesn’t make you a bad person.”

Are you ready to blog?
It’s easy to get started. There’s no cost, other than your time, and, if you’re speaking from personal experience, what it costs you to speak from your heart.

Brooke blogs to share with women like herself, and to let her friends and family know that she’s OK. “I think I’m helping other people feel more normal…the stigma hopefully will diminish in time.”

Blogging can be a positive experience, but there are emotional risks.

“I think that if more people blogged about STDs it might help reduce some of the stigma associated with them,” says Elizabeth. “However, I think it’s important to acknowledge that doing so is not without risks. Publicly acknowledging an STD infection may change the way that people around you treat you. It may even affect your employment—although it shouldn’t.”

Boundaries
It’s OK to not share every single thing in your life. Write honestly, but don’t fret about keeping some details private. It is your life, so you define the boundaries beyond which you’re not comfortable sharing.

Readers
If you write about it, they will come, but be prepared for the readers’ thoughts that may cascade upon you. Some comments you’ll treasure and some, well, let’s just say they’ll raise the eyebrows.

“I check daily for new comments and emails,” says Brooke. “The ones that touch me the most are people who found out the same way I did, or the ones who decided to have a baby after reading my story.”

There’s a yin yang to blogging, as there is elsewhere in life. Be prepared for the nasties you’ll find in the comments section of your blog.

“Although blogging can be a wonderful way to gather personal support, it may also have less positive results,” explains Elizabeth. “Comments can be negative, or even cruel and vindictive. It may be worth blogging anonymously if you are concerned about your privacy and the ramifications for exposure in your daily life; however, it is very difficult to ‘guarantee’ that your identity will not become known. This is particularly true if you are discussing sensitive issues such as those involving your sexuality.”

Last words
Bloggers always get the last word, and that’s no less true for our guests today.

Brooke on HIV: I live a normal life other than taking pills every day. I’m waiting to see what the disease does to me. I think all of us sit and wonder when it’s going to kick in, and what it’s going to do.
If you’re having unprotected sex, get tested. You never know. There are really no symptoms that would lead you to get the test, it’s better to know and get on meds now than find out when it’s too late and you’re really sick.

Sabina on HCV: [I want people to know] that we’re not harmful to others as long as we don’t share blood transferring items, such as razors, and toothbrushes. And that having HCV [hepatitis C virus] doesn’t set you apart from others even though it’s a serious virus.

Elizabeth on STDs: I don’t think you have to blog about STDs to help destigmatize them. Make a point of having open and honest discussions of sexuality with your partners and your family. Don’t allow people to get away with making cruel comments about infectious diseases or even “cute” jokes. And, finally, remember that a lot of the stigma surrounding STDs has to do with ignorance. Educate yourself—about how common STDs are, about testing, and about prevention—so that you can educate the people around you.

As a little girl, I dreamed of being a wife and mother with a home filled with children.

When I realized that “prince charming” wasn’t showing, I knew I could still be a mom. When I set out on the journey alone, I thought it would take forever, however I was a lucky one. I signed with an adoption agency in June of 2002, and my son was born in August 2002.

When the agency told me they had a birthmother looking for a single mom, I questioned why? In speaking to the birthmom she said “she had grown up in a household where her parents fought a lot, so her thought was if there was one parent she was ok with that.” Anyway, it worked out great for me.

The agency told me the mother was a drug user and had hepatitis B and C. I thought “OK so what does that mean?”

I was able to get the birthmom’s medical records as well as my son’s records, once he was born, and have then reviewed. At birth, my son’s blood was non-reactive to hepatitis C and of course he was given the vaccine for hepatitis B. OK, non-reactive that’s good right? Well it really doesn’t mean anything except that the virus is not active as of right now, and we would have to wait until he was 15 months old to run further blood work.

When I was asked if I still wanted to adopt him, I thought they were crazy, well of course. He was my son, it was meant for me to be his mom and my blessing from above. We plugged along with him over the first year having some issues, having to be withdrawn from the drugs he was born addicted to, having a bout of meningitis, bladder infections, a lot of virus issues etc. Then the dreaded 15 month time frame was here.

Ok we went and had the blood work and I just knew in my heart that since I had been told that there was less than a 1% chance that he would have hepatitis C that we would be doing this just to get the all clear. I remember it was right before Thanksgiving and I was going into the mall to shop when my cell phone rang. It was Ryan’s pediatrician who was a friend that I had worked with over the years. I couldn’t believe what I was hearing, his blood work was positive for hepatitis C. What, say that again? You have to be wrong, right?

No, he wasn’t wrong. He told me to enjoy the holiday and he would see me right after. Enjoy the holiday, are you kidding me, how would I ever enjoy anything again?

You see for me the first 15 months of my son’s life was spent dealing with the other issues, and not ever really thinking that we would have to deal with HCV. I didn’t really know a lot about it and my first thought was “Oh my God, I am going to have to watch my child suffer.”

Well over the next week I began researching and reading everything I could on hepatitis. By the time Ryan got in to see the GI specialist, I knew we had to run a genotype screening and viral load blood work. I was in an attack mode and wanted my baby fixed. Well I wish it was that easy. The GI physician here at our local Childrens’ Hospital told me that there was not much info on children dealing with this disease and he would follow Ryan with blood work and ultrasounds every six months, and at age 3 we would treat him.

WHAT, I wanted something done now. Of course I realized in my mind that that was not the protocol and that I had to trust the doctors. That was hard for me, I wanted to be in control over what happened with my son, not this horrible disease that could be eating away at his liver. How would I allow it to go on for another 2 years before we did anything? Of course, now I realize the harshness of the treatment, but at that time I just wanted it not to be true. I prayed that I would be strong for my son and be able to gain as much knowledge as I could about this monster living within his blood and liver.

(Guest post in a series from Sabina, our 15-year-old friend living with hepatitis C.)

Dear Readers,

Yesterday, I had my fourth interferon shot! And I didn’t feel any pain.

Yes, I was anxious but when I actually got the shot it was easy. So far, I’m lucky that I have not had any symptoms after the shot.

Sometimes I get headaches, nausea, and tired from the ribavirin pills. But I still feel upbeat and I’m really glad that so far I can do the sports I love to do.

Courtesy: Meredith James Johnstone

Last Tuesday, I started dance classes for the first time and I’m having great loads of fun. This Friday I have tryouts for volleyball. I’m excited for that. I don’t know if I can keep up both sports but I’m going to try.

Beyond sports, I feel like I’ve been able to do most activities and work at school. I haven’t missed any time, although I’ve been pretty tired. I’ve been going to bed early, like around 8 instead of 11. That’s a big difference but I’m tired and I get to the point where I can’t keep my eyes open any more. This makes it harder to get my homework finished, but if I work on managing my time I can get everything done.

My parents say that if I get too tired I will have to let some activities go. I realize I shouldn’t overwork myself. But it feels good to be active and to have goals set for myself.

One question I have for my readers is this—are there any other kids out there who are like me and going through this or thinking about getting treated? What are your views? What are the obstacles you are running into? And are you having any serious symptoms? I would love to hear from other people.

Disclaimer

The information on PKIDs' Blog is for educational purposes only and should not be considered to be medical advice. It is not meant to replace the advice of the physician who cares for you or your child. All medical advice and information should be considered to be incomplete without a physical exam, which is not possible without a visit to your doctor.